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KROGER PHARMACY #990
DSH450508 LION STAR NACOGDOCHES MEMORIAL HOSP
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Covered Entity Details
Entity Name
LION STAR NACOGDOCHES MEMORIAL HOSP
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450508
Entity Address
1204 NORTH MOUND STREET
NACOGDOCHES, TX 75961
Medicare Provider Number
450508
Participating Start Date
7/1/2024
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #990
Pharmacy Address
1215 N STREET
NACOGDOCHES, TX 75961
Pharmacy Comments
Contract Details
Approval Date
3/7/2012
Contract Begin Date
3/7/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
TIM HAYWARD, CEO
(936) 568-8520
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
2/27/2012
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